HealthWatch runs every other week as a regular Gazette feature, where medical journalist Evra Taylor Levy and emergency physician Eddy Lang help make sense of sometimes contradictory medical research.

What if one of the most widely used medical therapies was being called into question by some of the world’s leading specialists?

Such is the case with the group of anti-cholesterol medications called statins. Although they’ve been available for only 15 years, they have become a nearly universally used standard for the treatment of high cholesterol. But can they actually improve a person’s quality of life – and prolong their years – by preventing cardiovascular events, and death from heart attacks and strokes? This edition of HealthWatch discusses the encouraging results of a study on the benefits of these medications in the elderly, a positive counterpoint to the bad press statins have been getting lately.

The good, the bad and the ugly effects of high cholesterol. You’ve no doubt heard of “good” and “bad” cholesterol. HDL, or high-density lipoprotein, is the “good” cholesterol. The bulk of cholesterol, however, is LDL, or low-density lipoprotein, nicknamed the “bad” type because it promotes the buildup of plaque in the artery walls, which in turn can spell a heart attack or stroke. HDL has a cardioprotective effect as it carries LDL cholesterol away from the artery walls and back to the liver.

So, where’s the controversy?

Several recent large studies have called into question the widespread use of statins in patients who have high cholesterol but have not yet had a heart attack. They’ve shown that these drugs lower LDL cholesterol, but fail to have a meaningful impact on the incidence of cardiovascular events including heart attack, stroke – and death. This has raised the possibility that statins are actually harmful in some way and are somehow offsetting their cardiovascular benefits.

Physicians also worry about rare side-effects on the liver and severe muscle weakness and pain. Adding to the fray is the revelation that recent marketing campaigns have exaggerated study results that, upon careful analysis, are not so impressive after all.

Are there particular concerns regarding the elderly?

Yes. One of these is the fact that most research has targeted middle-aged people, rarely studying people over age 65. So it turns out to be a bit of a stretch to assume that the benefits of statins in younger people will also apply to the elderly.

In addition, many of our elderly take multiple medications daily, leading to a situation known as polypharmacy, which creates its own set of problems.

The study

Statins for secondary prevention in elderly patients, by Jonathan Afilalo et al. Journal of the American College of Cardiology, Vol. 51, No. 1, 2008.

What was this study about and how was it unique?

A McGill-based group of researchers countered the under-representation of the elderly in individual studies and extracted the data on the patients aged 65 years and over with known coronary artery disease from multiple studies, thus creating a large patient data pool from which more reliable conclusions could be drawn. After a thorough search of the world literature, they amassed the results on the elderly subset of patients from nine trials, or nearly 20,000 patients ages 65 to 82, from studies that compared a statin with a placebo; they followed them for at least six months.

Of note, by focusing on those patients who already had heart disease, they looked at the benefits of statins in a strategy called “secondary prevention.” Focusing on preventing a first heart attack or stroke in someone who has high cholesterol is called primary prevention, and is where the controversy lies.

What did the study show?

In contrast to previously mixed conclusions, this pooled study or meta-analysis demonstrated that statins, when taken for at least six months, carry a reduced risk of death from any cause. In addition, the study reported reductions in fatal heart attacks, stroke and the need for bypass surgery or angioplasty in the range of 20 to 30 per cent.

The results suggested that statins were actually more effective at prolonging life in the elderly than in younger patients. Extrapolating their results, the authors of an accompanying editorial deduce that an 85-year-old taking a statin can expect to increase life expectancy by two years, which in relative terms is far more than the four years that a 55-year-old might expect to gain.

Are there any caveats?

These results still might not apply to the very frail elderly patients who were probably not recruited into these studies. Unpleasant and potentially dangerous side effects can still necessitate stopping these drugs. Also, the only statins included in this study were pravastatin, simvastatin and fluvastatin, sold as Pravachol, Zocor and Lescol, respectively.

Are statins widely used?

Statins are a huge commitment: only 60 per cent of patients on the drug are taking them as prescribed after two years. Compliance aids and education are therefore needed. Some estimates suggest that not all eligible patients take a statin, and this gap between what is known and what physicians prescribe needs to be closed.

So, what’s the bottom-line message for people with high cholesterol?

Whether for primary or secondary prevention, and despite the common belief to the contrary, cholesterol-lowering medications cannot compensate for poor lifestyle choices like a lack of exercise, smoking and a poor diet.

However, despite the controversy related to primary prevention, it’s now clear that there are benefits in the elderly who have had a heart attack or stroke. This study presents very positive results that probably offset the burden of too many medications, possible side effects and the negative press that statins have been receiving lately.

Ensuring that eligible patients take statins, and take them as prescribed, despite the hassle, is something that healthcare providers, patients and families should definitely keep in mind. These drugs offer the elderly and their loved ones hope for a longer and heart-healthy future.

The material provided in HealthWatch is designed for general educational purposes only and does not pertain to individual cases. The information included should not replace necessary medical consultations with your own doctor or medical professional.

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